Feature

Why are some dentists a pain?

Public concern over NHS dentistry has risen in recent years. Maria Dickinson, Michael Calnan and Graham Manley look at the causes of dissatisfaction

Recent changes in NHS dental services have produced uncertainties for both practitioners and users. In 1992, cuts in the fees paid to dentists for providing NHS treatment fuelled dentists’ opposition to further changes to their remuneration system, published in the green paper, Improving NHS dentistry, in 1994. In this paper the government proposed to introduce local purchasing, and a new contract which included a new payment system.

Many dentists rejected the government’s proposals, and there were fears that the government would reduce dentistry funding. Until recently the majority of dentists have tended to do both public and private work, with only a minority working in purely private practices. Opposition to the government proposals, and financial difficulties, have led dentists to restrict the number of new NHS patients they accept.

Survey evidence shows that while most dentists still do some NHS work, only half regularly accept all categories of NHS patients.¹ In some areas such as the South East NHS care is becoming increasingly difficult to find.² There is also evidence of a high and increasing use of services providing emergency dental cover.

What are the implications for the public? The study reported here sheds some light on this question.³ We explored, through postal surveys of adult populations living in an inner city area (I) and semi-rural area (R) of southern England, the public’s concerns and complaints about NHS dental services over recent years. Random samples of 3,092 people from (R) and 3,001 from (I) were selected from electoral registers. Of those sent questionnaires 55 per cent responded in area R and 48 per cent in area I.³ The surveys were carried out in 1996/97.

Respondents were asked if over the last five years they had had any views/comments about dental services which they either expressed or would have liked to express to the dental services/service providers? Seventeen per cent in area R and 14 per cent in area I said they had had a view or comment about dental services.

Respondents in area R were asked what their comment was about. Most (99 per cent) involved a ‘complaint’ of some kind and, as the table shows, three-fifths (60 per cent) were concerns about a lack of access to general dental care (of which most were regarding the unavailability and higher cost of NHS dental care). A further fifth (20 per cent) of the complaints focused on the care provided by the dentists, particularly unsatisfactory or unnecessary treatment, or the dentist’s manner.

The issue of unnecessary or over-provision of dental treatment was raised by the Scharsheiff report and has become a contentious issue within general practice.⁴ Our study, however, showed that in relation to NHS dentistry only 6 per cent of the sample in the rural area and 9 per cent from the inner city felt they would receive excessive treatment. The story was different for perceptions of private care, with 29 per cent in the rural area and 32 per cent in the inner city area stating that they felt they would receive excessive treatment.

The majority (18 per cent) of the remaining fifth were critical of dentists in general in particular privatisation of dentistry and charges for treatment. Only a minority of those who had specific concerns (12 per cent in area R and 22 per cent in area I) said they had formally reported their complaint. This illustrates the obstacles that stand in the path of potential complainants. Of those in area R who formally reported complaints, fewer than one in five said that they experienced any difficulties in communicating their views although just over two-fifths were dissatisfied with the way their complaint was handled.

The respondents in area R said they did not report their comments mainly because they felt it would not result in any changes to the service (67 per cent), nobody would listen (43 per cent), and because they did not know who to notify (43 per cent). Certainly, when all respondents in both samples were asked whom they understood as being the first person to contact regarding complaints about NHS dental services, only around a third in both areas knew to contact the practitioner/practice involved. The first step in the complaints procedure introduced in April 1996 involves the user attempting to sort out the problem with the practitioner. There seemed a general lack of awareness of this at least among respondents in area R (only 4 per cent said they were aware of the new complaints procedures).

Were these complainants a distinct group with specific characteristics, or were they at one end of the continuum who were dissatisfied with the quality of dental care they received? A scale of user views about dental satisfaction was constructed from the survey responses to questions about access, cost, dentist’s manner, dentist’s technical skills, and pain management. On average those who complained scored lower (more dissatisfied) than those who did not report a complaint.

Those who have a complaint may reflect the ‘tip of the iceberg’ of wider public concerns about the provision of dental care in the sample as a whole. Certainly, statistical evidence from the survey showed that dissatisfaction with dental care was mainly to do with perceived barriers to care such as dislike of the dentist, difficulty getting NHS dental care, reluctance to pay for dental care, and difficulties paying for dental care.

The Social Attitudes Survey has shown increased dissatisfaction with NHS dentistry which has accelerated in recent years, in contrast to other areas of the NHS, such as GP services, where levels of satisfaction have remained about the same.⁵ Evidence from our study suggests that one of the major reasons for this is because of problems of access caused by increased charges and lack of availability of NHS dental care. Further evidence is required to find exactly the size and nature of the shift of dentists into private practice and why they find it more attractive than focusing mainly on NHS care.

Our evidence also points to an increasing pattern of attendance that primarily relates to negative oral symptoms, ie pain/discomfort. These symptoms tend to be related to the advanced stages of dental caries and sometimes periodontal disease. At this stage, advanced dental care or extraction may be the only option. Advanced dental care requires a commitment on the user’s part in terms of money and attendance, and the care may be considered a low priority by the patient. If this tendency continues unchecked, the inevitable result is a population with increasing tooth loss and more reliance on prosthetic replacements.

In dentistry, financial support tends to focus on care rather than prevention. This system of reimbursement to dentists is being reduced, but there is little sign of increased funding of a preventive public health strategy. If a strategy of improved, effective public health measures was comprehensively introduced, then the lack of regular attendance by users of the general dental practitioner may have little significance other than for the provision of advanced restorative care.